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CERTIFICATION <br /> The Applicant, Ore,, r,, Pe s f-r" (print applicant/company name), <br /> by rr '5, P�57 r' (print representative's name),as (print <br /> representative's title),does hereby certify that Fr, f L3-e c (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for To c/I (operation name), <br /> File Number M- <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal,and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant oye4,'4 P� �, -z-,/ Representative Name Crc,1'rr- P:5 a <br /> Date acy e- 0;-7 2- Title <br /> STATE OF ) <br /> )ss. <br /> COUNTY OF T,, ) <br /> Th foregoing was acknowledged before me this day of v 20?,by <br /> as " �:(;:,d,1: I <br /> � 05My Commission Expires: , C <br /> Notary Publ <br /> STEFFANY JOHNSTONE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20214004248 <br /> MY COMMISSION EXPIRES FEBRUARY 2,2025 <br />